Congenital anomalies of the coronary artery are rare. However, they can cause sudden death because of arrhythmia. We present a case of a 62-year-old man with severe aortic valve regurgitation associated with an anomalous origin of a narrowed right coronary artery (IB₂ according to the Shirani Classification) detected on preoperative coronary three-dimensional computed tomography (CT) . The patient underwent both aortic valve replacement for aortic regurgitation, and coronary artery bypass. The postoperative course was uneventful.

We report a rare case of a protruding tumor from the right atrial free wall into the cardiac sac. A cardiac tumor was incidentally detected in the right atrium of a 64-year-old man by transthoracic echocardiography. The tumor was located in the right atrial anterior free wall, infiltrating the right artrial appendage near the tricuspid valve annulus. It had an irregular surface, did not have a tumor stalk, and was considerably mobile. We resected the tumor and performed cryosurgical ablation of the remnant tissue to reduce the risk of local recurrence. Histopathologic examination confirmed the tumor to be metastatic malignant fibrous histiocytoma (MFH). The postoperative course was uneventful, and the patient was discharged 11 days after surgery. Follow-up computed tomographic scans and transthoracic echocardiography did not reveal any evidence of local cardiac recurrence or distant metastasis.

A 53-year-old man was admitted to Jichi Medical School Hospital because of low back pain and respiratory distress. Echocardiography revealed mitral valve regurgitation and mitral vegetations, and MR imaging showed destructive change in the lumbar vertebrae. The low back pain and inflammatory activity subsided with administration of antibiotics, but regurgitation-induced heart failure was medically intractable. The patient underwent mitral valve replacement with a bicarbon valve. The mitral valve showed destructive change with infective vegetation. Microbiologic study of preoperative blood samples and resected valve did not show any organism. Antibiotics were given for another 6 weeks. As of the last follow-up observation at 18 months, the patient was doing well.

Primary malignant cardiac tumors are extremely rare. Among these, leiomyosarcoma are particularly exceptional and only about 20 surgically treated cases have been extensively described. We describe a case of right atrial leiomyosarcoma which was accidentally found by computed tomography. The tumor was surgically resected under extracorporeal circulation. Two months later the patient had cerebral hemorrhage due to a brain metastasis, which almost completely disappeared after irradiation. There was no other evidence of recurrence for 12 months after operation.

We encountered a rare case of aortic regurgitation due to rheumatoid arthritis. A 53-year-old man was admitted with severe heart failure due to aortic regurgitation. He had been treated for rheumatoid arthritis for 5 years with methotrexate. After treatment for heart failure, his aortic valve was successfully replaced with an Omnicarbon prosthetic valve. Histopathological examination of the excised aortic valve showed rheumatoid granuloma. His post-operative course was uneventful.

Injury to the thoracic aorta is often fatal. We encountered a case of aortic rupture caused by a traffic accident. A 20-year-old man was transferred to our hospital because of right elbow fracture and enlargement of the upper mediastinum on X-ray. We diagnosed aortic isthmus rupture by chest CT with enhancement. He did not have chest pain, but complained of severe pain in the right elbow. His hemodynamic condition was stable, but his right arm become swollen with increasing sensory disturbance. Chest CT and blood cell count showed no interval change between results at a previous hospital and ours. So we decided to operate on his right arm before aortic rupture. After the open reduction of his fractured elbow, pleural effusion increased although his hemodynamic condition was stable. Then the descending aorta was replaced under partial cardio-pulmonary bypass. His post-operative course was uneventful.

Injuries to the aorta complicating cardiovascular operations can be very challenging. This type of injury is usually related to manipulation of the aorta during surgical exposure or aortic cannulation. From March 1994 to October 1997, five patients with intraoperative injuries to the thoracic aorta occurred. Their ages ranged from 7 to 71 years old (mean, 43.5 years). Two were male and 3 female. Intraoperatively, trouble occurred suddenly due to acute aortic dissection related to aortic traumatic hemorrhagic disruption in three patients, and aortic cannulation in two patients. The confirmation of the diagnosis was prompted clinically, and all patients immediately underwent further surgical intervention. In terms of technique, we used a cardiopulmonary bypass (mean cardiopulmonary bypass time 239min, range 196 to 367min), and hypothermic circulatory arrest (mean arrest time 34min, range 20 to 44min, at deep hypothermia with 21.0°C urinary bladder temperature) during repair. Retrograde cerebral perfusion was utilized in two cases to assure protection for cerebral damage. Fortunately, there was no postoperative neurological complication and no hospital death in any of the cases. When such intraoperative injuries of the aorta once occur repair using aortic clamps often fail or is not feasible, and in such cases hypothermic circulatory arrest combined with retrograde cerebral perfusion should be applied to resolve this type of the serious troubles.

To avoid homologous blood transfusion, the effectiveness of autologous blood predonation was evaluated in patients with elective abdominal aortic aneurysm (AAA) repair. From January 1993 to July 1996, 53 patients underwent Y graft replacement by using autologous rapid transfusion device AT1000^® (Electromedics. Inc, Englewood, CO). The patients were devided in to 3 groups. Thirty one patients had no blood donation (Group A). Twelve patients had 400ml blood donation with administration of an iron preparation (Group B). Ten patients donated the same amount of blood as those in Group B, with administration of both an iron preparation and recombinant human erythropoietin (rHuEPO) (Group C). There were no significant differences in terms of age, gender, operating time, intraoperative bleeding, and total amount of homologous and autologous blood transfusion in the 3 groups. In Group A, the mean volume of homologous blood transfusion was 250±370ml and in both Groups B and C, no homologous blood was required and 400ml autologous blood was used. Homologous blood transfusion was avoided in 58.9 (18/31) of patients in Group A and all of the patients in Groups B and C. Due to the blood predonation prior to surgery, a hemoglobin level decreased significantly at the time of operation in Group B (without rHuEPO), but in Group C (with rHuEPO) the hemoglobin level was kept constant. During the first postoperative week, the minimum hemoglobin level in Group C was significantly higher than in the other groups. In conclusion, by donating 400ml autologous blood before surgery and using an intraoperative autotransfusion system, homologous blood transfusion could be avoided in elective AAA repair. With rHuEPO, the hemoglobin level could be maintained, despite predonation and intraoperative blood loss.

Fifty-two year-old woman was operated for type A acute dissection of the aorta superimposed on pre-existing post-stenotic dilatation dut to congenital aortic valve stenosis. The left main coronary artery was discontinued by dissection. Aortic valve replacement, replacement of ascending aorta by woven-Dacron graft and saphenous vein graft between the left anterior discending artery and the prosthetic graft. Compression gauze around the site of the anastomoses and the prosthetic graft was useful to control of intractable bleeding. The gauze could be extracted twenty-eight hours after the operation by platelet and plasma transfusion. She was well eleven months after the operation.

Eleven cases underwent tricuspid valve replacement with bioprosthetic heart valve between 1981 and 1990. Mean age was 51±12 years old and mean follow up period was 40±40 months. Mitral valve replacement in ten cases and aortic valve replacement in one underwent simultaneously. Warfarin and dipyridamole were prescribed for post-operative anti-coagulant therapy. Post-operative early death within 30 days was seen in two cases and late death was in two cases. Five years survival rate including early death was 70±14% and nine years survival rate was 54±18%. All seven cases excluding demised cases were III°or IV°in NYHA classification preoperatively but six were I°or II°at postoperative period. Preoperative functional status of all fatal cases were IV°. Cardio-thoracic ratio was 76.2±12.8% pre-operatively, 67.7±9.0 one year after operation, 66.3±7.8% three years after operation and 68.9±9.3 five years after operation. In conclusion post-operative cardiac function ameliorated, but could not return to fairly satisfactory state.